HAND SURGERY AND MICROSURGERY
The Vastus Lateralis Muscle Flap in Head and Neck Reconstruction
An Alternative Flap for Soft Tissue Defects
Jonas A. Nelson, BA, Joseph M. Serletti, MD, and Liza C. Wu, MD
Abstract: The reconstructive ladder for large head and neck defects includes
a number of muscle free flaps. One ideal flap that continues to be underuti-
lized is the vastus lateralis muscle free flap.
Between April and October 2008, 5 patients underwent head and neck tumor
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extirpation with reconstruction utilizing a vastus lateralis muscle free flap.
All flaps survived with no recipient or donor site complications. The
procedure did result in a small area of numbness on the donor thigh in all
patients.
The vastus lateralis muscle flap is an underutilized alternative for recon-
struction of deep soft tissue defects of the head and neck. Its advantages
include its consistent anatomy and large caliber pedicle, adequate volume, a
location enabling a 2-team approach and low donor site morbidity. This
versatile flap should be included as an option in complex soft tissue
reconstructions of the head and neck.
Key Words: vastus lateralis, free flap, head and neck, microsurgery,
reconstruction, plastic surgery
(Ann Plast Surg 2010;64: 28 –30)
F ree tissue transfer has become an integral component of head and
neck reconstruction1 and has facilitated improved functional and
cosmetic outcomes since its introduction.2 Although the reconstruc-
tive ladder in head and neck tumor ablative surgery has changed
because free tissue transfer is now often the first reconstructive
choice as opposed to simply the last resort,3,4 reconstructions after
tumor extirpations still present a challenging dilemma in the need
for soft tissue.
Large, deep defects of the head and neck requiring soft tissue
but no cutaneous recruitment have historically used the rectus
abdominis, latissimus dorsi, or serratus anterior muscle free flaps.
Although effective, each has significant disadvantages to its use.
One muscle flap that continues to be underused in head and neck
reconstruction, even with several notable advantages and few dis-
advantages, is the vastus lateralis muscle free flap. This flap is ideal
for soft tissue defects of the head and neck. The vastus lateralis
myocutaneous and pure muscle flaps with secondary skin grafting
have been described;2 however, there are few recent articles describ-
ing the utility of the pure muscle flap for deep soft tissue defects not
requiring cutaneous tissue recruitment to the head and neck.
In this case series, we report the use of the vastus lateralis
muscle free flap in head and neck reconstruction following tumor
extirpation and advocate for the inclusion of this flap in the standard
Received November 17, 2008, and accepted for publication, after revision,
February 20, 2009.
From the Division of Plastic Surgery, University of Pennsylvania School of
Medicine, Philadelphia, PA.
The authors have nothing to disclose, as no products or devices were used in this
manuscript and no financial conflicts of interest are present.
Reprints: Liza C. Wu, MD, Division of Plastic Surgery, University of Pennsyl-
vania, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104. E-mail:
Liza.Wu@uphs.upenn.edu.
Copyright © 2009 by Lippincott Williams & Wilkins
ISSN: 0148-7043/10/6401-0028
DOI: 10.1097/SAP.0b013e3181a20cf1
28 | www.annalsplasticsurgery.com
armamentarium of soft tissue options for head and neck reconstruc-
tive surgery.
PATIENTS AND SURGICAL TECHNIQUE
Between April and October 2008, 5 patients underwent head
and neck tumor extirpation with reconstruction utilizing a vastus
lateralis muscle free flap. Patient demographics, tumor histopathol-
ogies, defect locations, and flap characteristics were obtained from
medical records (Table 1).
The technique of dissection is as follows. A line is drawn
from the anterior superior iliac spine to the lateral border of the
patella, and an incision is made 5 to 10 cm distal to the trochanter.
This incision is designed lateral to the lateral femoral cutaneous
nerve, which is often visualized and preserved in the dissection.
Once through the subcutaneous fat, the rectus femoris and the vastus
lateralis muscles are identified. The rectus femoris muscle is re-
tracted medially allowing visualization of the descending branch of
the lateral femoral circumflex artery. The appropriate size of vastus
lateralis is then measured based on the defect and the needed pedicle
length is measured. The pedicle is dissected out and branches to the
rectus femoris and proximal vastus lateralis muscle can be ligated to
extend the pedicle length (Fig. 1). This flap can be tailored to fit the
defect, both with regards to the pedicle length and muscle width,
length, and depth (Fig. 2). In doing so, it is possible to harvest only
a portion of the muscle, leaving the remainder innervated and
functional. The donor site incision is closed primarily.
RESULTS
All flaps survived with no complications. The donor sites
have healed, and based on subjective clinical examination and
patient interview, there has been no decrease in leg strength in the
donor thigh. The procedure did result in a small area of numbness on
the lateral aspect of the donor thigh in all patients, measuring
approximately 2 inches in diameter.
DISCUSSION
Microvascular surgery has dramatically changed functional
and cosmetic outcomes in head and neck surgery. The choice of free
tissue transfer is related not only to the defect but also to the
individual’s comorbidities, body habitus, and prognosis.4 The at-
tributes that the chosen flap ideally exhibit to achieve the recon-
structive goals include a long and high caliber pedicle with consis-
tent anatomy, low donor site morbidity, and adequate tissue
volume.2
Commonly used flaps for deep defects each have potential
disadvantages to use. The rectus abdominis flap, though providing
an excellent pedicle caliber, a large volume of muscle and the
potential for simultaneous flap harvest, disrupts the integrity of the
abdominal wall.5 Additionally, this flap often has a short pedicle
length. The latissimus dorsi flap also provides volume and a con-
sistent, long pedicle, however requires intraoperative repositioning,6
which prevents simultaneous flap raising and tumor ablation. The
main disadvantage to the serratus anterior is its inadequate volume.
Though these flaps have the mentioned disadvantages, an alternative
Annals of Plastic Surgery • Volume 64, Number 1, January 2010
Annals of Plastic Surgery • Volume 64, Number 1, January 2010 An Alternative Flap for the Head and Neck

TABLE 1. Patient Demographics, Tumor Properties, and Flap Characteristics

Flap Flap Arterial
Age, FLAP Length Width Pedicle System
Patient Sex Defect Location Histology Flap Design Area (cm) (cm) Length Utilized Complications
1 69, M Retropharyngeal space Poorly differentiated carcinoma VL muscle 25 5 5 9 Facial artery None
and infratemporal with adenosquamous features
fossa
2 41, F Maxillary sinus, base Adenoid cystic carcinoma VL muscle with 63 9 7 12 Facial artery None
of the anterior fascial graft
cranial fossa
3 70, M Left anterior and Sinonasal basaloid squamous VL muscle 96 12 8 9 Facial artery None
middle cranial fossa cell carcinoma
and orbit
4 59, F Orbit, frontal bone, Undifferentiated sinonasal VL muscle 96 12 8 12 Facial artery None
anterior cranial carcinoma
fossa, and dura
5 62, F Left parotid fascial Recurrent benign mixed tumor VL muscle with 54 9 6 9 Facial artery None
space, mastoid bone motor nerve
graft

flap that has the ideal attributes for deep soft tissue head and neck
defects is the vastus lateralis muscle flap. This muscle flap addresses
each of the disadvantages of the more commonly used flaps.

FIGURE 1. The raising of the vastus lateralis muscle flap (top) FIGURE 2. The tailored flap used in patient 5 (top) and the
and the deep defect following tumor ablation (bottom) in pa- defect following tumor resection (bottom). Note the difference
tient 2. Note the length and caliber of the pedicle. in tailored flap size compared with that of patient 2 (Fig. 1).

© 2009 Lippincott Williams & Wilkins www.annalsplasticsurgery.com | 29

Nelson et al
The vastus lateralis muscle flap has a large caliber pedicle
with consistent anatomy, which allows for a simple dissection from
the lateral thigh.2,7,8 This pedicle includes a 2- to 3-mm artery and
a 2- to 4-mm vein and can be up to 20 cm in length.7,9 Such length
enables anastomosis in the contralateral neck if ipsilateral recipient
vessels are not available. Additionally, the muscle has adequate
volume to fill large defects. Furthermore, the patient does not require
repositioning to raise the flap, which facilitates a 2-team approach
hence reducing total case time. Lastly, there is very little donor site
morbidity associated with the flap.7,10,11 Yet even given these
proven attributes, the flap continues to be overlooked by the recon-
structive community.
The flap was first described for use in head and neck cancer
reconstructions in the 1990s7 and was described in 2003 as part of
a larger case series.12 Comments that followed suggested that this
flap could soon become a “work-horse” flap in skull base surgery.13
More recently, the vastus lateralis muscle flap with skin graft was
described for superficial defects.14,15 Although these case reports
give convincing examples supporting the advantages of the vastus
lateralis flap, it continues to be overlooked and omitted from the
standard algorithms of reconstructive practice.4,16
In summary, the vastus lateralis muscle flap is an underuti-
lized alternative for reconstruction of deep soft tissue defects of the
head and neck. The advantages of the flap include its consistent
anatomy and large caliber pedicle, adequate volume to fill large
defects, a location that enables a 2-team approach therefore reducing
operative time and low donor site morbidity. As it has achieved
comparable results functionally and esthetically to more commonly
used flaps yet allows such a 2-team approach and lower donor site
morbidity, preference should be given to this flap.8 Yet, it continues
to be overlooked as a soft tissue option in the algorithm for head and
neck free flap reconstruction. Given its favorable characteristics, this
versatile flap continues to have the potential, in time, to be a
“work-horse” flap13 and should be included as an option in complex
soft tissue reconstructions of the head and neck.
30 | www.annalsplasticsurgery.com
Annals of Plastic Surgery • Volume 64, Number 1, January 2010
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© 2009 Lippincott Williams & Wilkins